Psychometric properties of the Arabic version of Connor-Davidson Resilience Scale in a sample of Lebanese women

Purpose Resilience is defined as the ability to face adversities with positive outcomes. Various scales have been utilized, including 25-item Connor-Davidson Resilience Scale (CD-RISC), to evaluate resilience among populations. Resilience research is scarce, particularly in Lebanon as no such scales have been validated. Thus, in the present work, we aimed to assess the psychometric properties of the Arabic version of CD-RISC. Patients and methods The study was conducted at the Women’s Health Center at the American University of Beirut Medical Center among Lebanese women presenting to the obstetrics and gynecology clinics. Internal validity of the Arabic CD-RISC was examined. Pearson’s correlation coefficients between the scores of the Arabic version of CD-RISC and the other related constructs (Rosenberg Self-Esteem Scale, Dispositional Hope Scale, Life Orientation Test, and Positive and Negative Affect Schedule) were assessed to evaluate its divergent and convergent validity. We collected responses from a total of 63 Lebanese women. Results The studied scale displayed a high internal consistency. Adequate correlation coefficients were manifested by the significant positive moderate to strong and negative moderate correlations between the Arabic CD-RISC and the other related constructs. Conclusion This is the first study to validate the Arabic version of the CD-RISC in a sample of Lebanese women. The findings of this study provide evidence that the Arabic version of CD-RISC is a reliable and valid tool for the evaluation of resilience among Lebanese women.

Introduction Resilience, the ability to "bounce back" from stress, as a construct has garnered increasing attention when looking at resistance to one's risk of developing poor outcomes in the face of adversity [1]. As an adaptation process, across the lifespan, the experience of resilience will vary [2].
In the Arab World in general and in Lebanon, mental health research is focused on poor psychiatric outcomes, including rates of depression, anxiety, and post-traumatic stress syndromes. Resilience research is scarce, partly due to the lack of consensus on the scales used to measure it [2]. A recent methodological review identified three questionnaires with high ratings for their psychometric properties in capturing resilience in an adult population [2], among which is the Connor Davidson Resilience Scale (CD-RISC) [3]. No such scales have been found validated in the Arabic language. A study looking at resilience in Palestinian adolescents in Gaza [4], used 'minimal to no anxiety and depression' on the Arabic versions of the Beck Depression Inventory and the Beck Anxiety Inventory as a proxy to resilience.
Women's mental health is particularly important to examine in current times. Women are more likely to develop post-traumatic stress disorder in their lifetime than men [5][6][7][8]. In light of this past year's events in Lebanon, including the critical economic situation, due to both political turmoil and the COVID-19 pandemic, and a recently devastating atomic equivalent blast in the capital, resilience can no longer be avoided as an outcome when studying trauma in women. Connor and Davidson (2003) developed a self-report tool to quantify resilience drawing participants from various settings. This 25-item tool is based on a five-factor structure of the resilience construct: personal competence, high standards, and tenacity; trust in one's instincts, tolerance of negative affect, and strengthening effects of stress; positive acceptance of change and secure relationships with others; control; spiritual influences. It has been accurately translated into the Arabic language, the official language of Lebanon [9]. As such, we obtained the permission of the original authors to explore the psychometric properties of the Arabic version of the scale once applied to a Lebanese population of women. Thus, the reliability and validity of the scale in Lebanese women were assessed.

Study design
This was a cross-sectional study conducted at the Women's Health Center at the American University of Beirut Medical Center among Lebanese women presenting to the obstetrics and gynecology clinics between the ages of 18 and 65 between October and December 2020. We designed a questionnaire that consists of the patients' demographics, CD-RISC scale, in addition to multiple instruments outlined before that were used for the purpose of assessing the convergent and divergent validity of CD-RISC. Ethical approval was granted by the Institutional Review Board (IRB) of the Human Research Protection Program (HRPP) at the American University of Beirut (IRB Number: SBS-2020-0407). Global self-worth. One of the main constructs defining psychological wellbeing is selfesteem. The Rosenberg Self-Esteem Scale (RSES), measures the subjective evaluation of one's self-worth [10,11]. The scale contains 10 items, all items are on a 4-point Likert scale, and higher scores are correlated with better self-worth. RSES has been shown to have good validity and reliability among different samples including Arabic-speaking populations [12,13]. We obtained permission to use the back translated Arabic version from authors of Zayed et al, 2016. Since self-esteem is usually perceived as an indicator of better mental health, resilience was found to be positively correlated with self-esteem [14]. The Pearson's correlation coefficient between self-esteem and resilience using the Rosenberg scale was 0.53 (N = 246, p<0.001) [15].
Dispositional hope. Hopefulness is at the core of the ability to recover after adversity. It was assessed using the Arabic version of the Dispositional Hope Scale (DHS) [16]. The 12-item self-report scale has been widely used in various populations including Arabic speaking populations [17]. The Arabic version was validated in a Lebanese population with an internal consistency of alpha = 0.87 [18]. Permission to use the latter was obtained from authors of Ilyas & Kazarian, 2017. Hope is positively correlated with resilience as observed using the Dispositional Hope Scale (N = 246, Pearson r = 0.68, p<0.001) [15].
Optimism. Optimism, the cognitive outlook at the core of favorable outcomes, is also at the core of resilience. Life Orientation Test (LOT) [19] and its revised form (LOT-R) are the most widely used measures of optimism. The 10-item self-reported Arabic LOT-R consists of three optimism items, three pessimism items, and four filler items. Respondents rate items on a 5-point Likert scale, with higher scores indicating a greater disposition for a positive outlook. We obtained permission from Ilyas & Kazarian (2017) to use the Arabic version, which had an internal consistency of alpha = 0.62. The English version had a reported internal consistency of 0.78 [20]. The Life Orientation scale was found to have positive correlation with resilience as optimism is linked to resilience in general (N = 246, Pearson r = 0.55, p<0.001) [15].
Positive and Negative Affect. The Positive and Negative Affect Schedule (PANAS) [21] is a 20-item scale consisting of two subscales, each having 10 affective descriptors. Positive Affect indicates emotional wellbeing, including joy, inspiration, enthusiasm, whereas the Negative Affect subscale measures emotional distress, including anger, guilt, disgust and anxiety. Each item is rated on a 5-point Likert scale, and higher scores indicate a higher subscale measure. We obtained permission to use the Arabic version of the PANAS from Ilyas & Kazarian (2017). Comparing resilience with positive and negative emotions showed that CD-RISC was positively correlated with a positive affect score (N = 246, Pearson r = 0.69, p<0.001), and negatively correlated with a negative affect score (N = 246, Pearson r = 0.44, p<0.001) [15].

Statistical analysis plan
Statistical analysis was performed using SPSS 25 statistical software package (IBM, USA). Descriptive analyses were performed for all scores obtained from the Arabic version of CD-RISC. Pearson's correlation coefficients between the scores of the Arabic version of CD-RISC and other related constructs were calculated for the evaluation of divergent and convergent validity. Also, inter-item correlations and internal validity were examined. Level of significance was set at α = 0.05.

Results
A total of 63 Lebanese women participated in this CD-RISC validation study. Participants had a mean age of 28.48 ± 4.98 years. The age distribution of the sample population is presented in Fig 1. Table 1summarizes the scores of the studied scales among our sample population.

Reliability
The Cronbach's alpha for the Arabic version of CD-RISC Arabic was reported to be 0.89 (95% confidence interval [CI]: 0.832-0.919). Results showed that the 25 items of the Arabic CD-RISC had a relatively high internal consistency among our participants.

Convergent validity
We present the Pearson correlation coefficients (r) for Arabic CD-RISC and the following scales measuring self-esteem (RSES), dispositional hope (DHS), optimism (LOT), and positive affect (PANAS) in Table 2.

PLOS ONE
The highest correlation was found between CD-RISC and positive affect of PANAS (r = 0.63, p <0.0001). Similarly, each of the scales RSES, LOT, DHS revealed a moderately strong correlation with CD-RISC (r = 0.56, 0.54 and 0.5 respectively).

Divergent validity
CD-RISC possessed a significant yet weak-moderate negative correlation with the negative affect items of PANAS (r = -0.4, p <0.0001).

Discussion
The objective of this study was to evaluate the psychometric properties of the Arabic version of the CD-RISC in a Lebanese sample of women. The results indicated that the reliability and validity of the Arabic version of the CD-RISC are adequate among our studied Lebanese women sample.
Establishing the internal consistency of the Arabic version in a Lebanese population is essential for future evaluation of resilience. The reliability of the used Arabic CD-RISC is comparable to the results of the original research that developed the adapted Arabic version of the CD-RISC resilience instrument [9]. In fact, Cronbach's alpha is almost identical in both studies (0.89).
Convergent and discriminant validities of the used scale were computed to determine its validity among the studied sample. The convergent validity of Arabic CD-RISC was confirmed by the significant positive correlation with the positive affect of the PANAS scale. This comes in line with several studies revealing that highly resilient people cultivate their positive emotionality to overcome adverse events [22]. This makes positive affect an essential unit of the psychological resilience of an individual. Although moderate, the negative correlation between the negative affect of PANAS and CD-RISC establishes an extension of the findings where resilience is not considered a trait only but also a process based on myriad stressors and the negative affects coupled with it [23]. Similarly, a moderate correlation coefficient existed between CD-RISC and each of RSES, DHS, and LOT. Indeed, the latter are closely aligned constructs with resilience, as they all correlate with positive emotionality and optimistic outlook against hurdles [24][25][26].

PLOS ONE
The validation of the CD-RISC in the Arabic language has great implications on future resilience research in Lebanon and the region. Since its inception, Lebanon has been crippled by constant internal and external conflicts and instabilities. It has been repeatedly shaken by armed conflicts, unrest, and turmoil over the decade, leaving a notable mark on its people at both physical and psychological levels [27]. Nevertheless, the Lebanese people have never before experienced a more dreadful event than the recent August 4th, 2020 Beirut explosion [27]. The explosion was preceded by the October 17th, 2019 revolution and followed by an economic crisis, a global pandemic, and political violence [27].
However, despite the extensive history of economic and political grievances, studies conducted over the past 50 years have shown that Lebanese people tend to adapt fairly well to hardships [28]. This has been eminent in their ability to maintain functionality in academic, social, and occupational settings. It has been proposed that the Lebanese people's ability to cope with distress has been part of the Lebanese identity transmitted through generations [29]. This might provide them with a sense of coherence and hope in their future. However, there hasn't been any empirical studies that examined these claims on the Lebanese population, as these explanations were theorized by authors but were not backed up by neither quantitative nor qualitative data.
Literature suggests that childhood and adolescence are two critical developmental periods of heightened brain plasticity and increased sensitivity to environmental stressors [30,31]. Exposure to adversities during these two developmental periods affect the stress response system and brain circuit that mediates emotional regulation [30,32]. Studies in children who show features of resilience despite early trauma have identified crucial psychosocial factors that promote resilience, most prominently the formation of a solid bond with parents and family stability [33,34]. The Lebanese culture is known to be collectivistic, with family support and values playing a salient role in the child's life. This culture might be a reason for the resilient nature of the Lebanese people as they rely highly on psychosocial factors to promote coping with hardships. As evident from the above, the validated Arabic version of the CD-RISC is essential to further examine these claims on the Lebanese population after the cascade of devastating events that occurred over the past 2 years. Having an adequate instrument to measure resilience in the Lebanese population will prove to further advance empirical research examining the features and drivers of this apparent resilience.
Further, it is important to point out some limitations. The data was collected from a single center and the majority of our participants had high educational level and good socioeconomic status. Also, the sample size was limited. This may decrease the generalizability of the results.

Conclusion
This is the first study to validate the Arabic version of the Connor-Davidson Resilience Scale. We propose that the Arabic version of the CD-RISC has good psychometric properties. Although the study presents limitations, the Arabic version of the CD-RISC is a reliable and valid tool to evaluate resilience in Arabic-speaking women. Future studies should focus on empirically evaluating resilience, sense of coherence, and hope in the Lebanese population after the events of the last two years and consequently investigating the implications such events had on mental health. In addition, examining protective and moderating factors such as coping mechanisms is essential to fill in the gap in the trauma literature in the region.